Failure to Complete Required Background Checks for New Staff
Penalty
Summary
The facility failed to implement its abuse and neglect prevention policies by not completing required pre-employment background checks for four sampled staff members, including LPNs. Specifically, the facility did not have documentation of criminal background checks being requested or received for these staff, despite their employment and active work on the floor. While checks of the Nurse Aide (NA) Registry, Employee Disqualification List (EDL), and Nurse License Verification Report were documented as completed several days after the staff began working, the criminal background checks were missing from all four personnel records reviewed. Interviews with facility leadership revealed confusion and lack of clarity regarding the background check process. The Director of Nursing (DON) was unsure of the specific checks included, and the Business Office Manager (BOM) stated that background checks were now handled by the corporate office, which had recently experienced staffing changes and lacked proper access to complete the checks. Prior to the corporate transition, background checks were conducted in-house and included all required verifications. The Administrator also indicated unfamiliarity with the timing and process for completing all necessary checks. As a result, the facility did not follow its own policy or regulatory requirements for background investigations prior to allowing staff to work.